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What Type of Provider Are You *
Please select an option below *
Please select the products for which you wish to contract required required *
Please select the services for which you wish to contract required required *
Numbers only
Numbers only.
Numbers only

Before submitting this form, please download the documents listed below by right-clicking and choosing “save link as” or “save target as.”  Once the documents are complete, they must be uploaded to the corresponding upload option below.

NOTE:  The contracting process cannot begin unless all documents are submitted and accurate. Prior to submitting, please verify there are no discrepancies in the information provided and the TIN/NPI included on the forms align with documentation submitted to the Ohio Department of Medicaid, if contracting for Medicaid/MyCare.

As listed on the Form W-9
Numbers only
Numbers only.
Numbers only
Additional Counties Served
(May be displayed in provider directory.)

Before submitting this form, please download the documents listed below by right-clicking and choosing “save link as” or “save target as.”  Once the documents are complete, they must be uploaded to the corresponding upload option below.

NOTE:  The contracting process cannot begin unless all documents are submitted and accurate. Prior to submitting, please verify there are no discrepancies in the information provided and the TIN/NPI included on the forms align with documentation submitted to the Ohio Department of Medicaid, if contracting for Medicaid/MyCare.

Upload a completed Medicaid Attachment C PDF form document above
Upload a completed W-9 PDF form document above
Upload a completed Disclosure of Ownership PDF form document above
Upload a completed Provider Location PDF form document above
Upload a completed New Provider Enrollment PDF form document above
Please select the products for which you wish to contract required *
Please select the services for which you wish to contract required *
As listed on the Form W-9
Numbers only.
Numbers only.
Numbers only

Before submitting this form, please download the documents listed below by right-clicking and choosing “save link as” or “save target as.”  Once the documents are complete, they must be uploaded to the corresponding upload option below.

NOTE: The contracting process cannot begin unless all documents are submitted and accurate. Prior to submitting, please verify there are no discrepancies in the information provided and the TIN/NPI included on the forms align with documentation submitted to the Ohio Department of Medicaid, if contracting for Medicaid/MyCare. 

Upload a completed Medicaid Attachment C PDF form document above
Upload a completed Disclosure of Ownership PDF form document above
Upload a completed W-9 PDF form document above
Upload a completed Provider Location PDF form document above
Upload a completed New Provider Enrollment PDF form document above
Please select the additional products for which you wish to contract required *
Please select the additional services for which you wish to contract required *
As listed on the Form W-9
Numbers only.
Numbers only.
Numbers only

Before submitting this form, please download the documents listed below by right-clicking and choosing “save link as” or “save target as.”  Once the documents are complete, they must be uploaded to the corresponding upload option below.

NOTE:  The contracting process cannot begin unless all documents are submitted and accurate. Prior to submitting, please verify there are no discrepancies in the information provided and the TIN/NPI included on the forms align with documentation submitted to the Ohio Department of Medicaid, if contracting for Medicaid/MyCare.

  • If adding a new group practice under an existing TIN–
    • Medicaid Attachment C - (if contracting for Medicaid/MyCare)
    • New Location Form
    • New Provider Enrollment Form(s) to add fewer than 5 practitioners or roster to add 5 or more practitioners to that group/location
  • If adding new services under an existing TIN –
    • New Provider Enrollment Form(s) to add fewer than 5 practitioners or roster to add 5 or more practitioners to that group/location.
  • If adding new products under an existing TIN – no documents are needed

If you are only submitting the direct roster for several practitioners please us the upload option for the New Practitioner Enrollment form to attach the roster.

Upload a completed Medicaid Attachment C PDF form document above
Upload a completed Disclosure of Ownership PDF form document above
Please select the products for which you wish to contract required *
Please select the services for which you wish to contract required *
What type of facility is this? required *
As listed on the Form W-9
Numbers only.
Numbers only.
Numbers only
(May be displayed in provider directory)

Before submitting this form, please download the documents listed below by right-clicking and choosing "Save link as" or "Save target as." Once the documents are complete, upload to the corresponding upload option at the end of this page.

NOTE:  The contracting process cannot begin unless all documents are submitted and accurate. Prior to submitting, please verify there are no discrepancies in the information provided and the TIN/NPI included on the forms align with documentation submitted to the Ohio Department of Medicaid, if contracting for Medicaid/MyCare.

Please select the additional products for which you wish to contract required *
Please select the additional services for which you wish to contract required *
What type of facility is this? required *
As listed on the Form W-9
Numbers only.
Numbers only.
Numbers only

NOTE:  The contracting process cannot begin unless all documents are submitted and accurate. Prior to submitting, please verify there are no discrepancies in the information provided and the TIN/NPI included on the forms align with documentation submitted to the Ohio Department of Medicaid, if contracting for Medicaid/MyCare.

 

  • If adding new services under an existing TIN – No documents are required